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REVISTA BRASILEIRA DE ANESTESIOLOGIA
Official Publication of the Brazilian Society of Anesthesiology www.sba.com.br
SCIENTIFIC ARTICLE
Orotracheal intubation and temporomandibular disorder: a longitudinal controlled study Cláudia Branco Battistella a,∗ , Flávia Ribeiro Machado b , Yara Juliano c , Antônio Sérgio Guimarães a , Cássia Emi Tanaka a , Cristina Talá de Souza Garbim a , Paula de Maria da Rocha Fonseca a , Monique Lalue Sanches a a
Morphology and Genetics Department, Escola Paulista de Medicina da Universidade Federal de Sao Paulo, São Paulo, SP, Brazil Anesthesiology, Pain and Intensive Care Department Escola Paulista de Medicina da Universidade Federal de Sao Paulo, São Paulo, SP, Brazil c Public Health Department, Santo Amaro University, São Paulo, SP, Brazil b
Received 7 May 2014; accepted 26 June 2014
KEYWORDS Temporomandibular joint disorders; Myofascial pain syndromes; General anesthesia; Intubation; Orofacial pain
∗
Abstract Background and objectives: To determine the incidence of signs and symptoms of temporomandibular disorder in elective surgery patients who underwent orotracheal intubation. Methods: This was a longitudinal controlled study with two groups. The study group included patients who underwent orotracheal intubation and a control group. We used the American Academy of Orofacial Pain questionnaire to assess the temporomandibular disorder signs and symptoms one-day postoperatively (T1), and the patients’ baseline status prior to surgery (T0) was also recorded. The same questionnaire was used after three months (T2). The mouth opening amplitude was measured at T1 and T2. We considered a p value of less than 0.05 to be significant. Results: We included 71 patients, with 38 in the study group and 33 in the control. There was no significant difference between the groups in age (study group: 66.0 [52.5---72.0]; control group: 54.0 [47.0---68.0]; p = 0.117) or in their belonging to the female gender (study group: 57.9%; control group: 63.6%; p = 0.621). At T1, there were no statistically significant differences between the groups in the incidence of mouth opening limitation (study group: 23.7% vs. control group: 18.2%; p = 0.570) or in the mouth opening amplitude (study group: 45.0 [40.0---47.0] vs. control group: 46.0 [40.0---51.0]; p = 0.278). At T2 we obtained similar findings. There was no significant difference in the affirmative response to all the individual questions in the American Academy of Orofacial Pain questionnaire.
Corresponding author. E-mails:
[email protected],
[email protected] (C.B. Battistella).
http://dx.doi.org/10.1016/j.bjane.2014.06.008 0104-0014/© 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Please cite this article in press as: Battistella CB, et al. Orotracheal intubation and temporomandibular disorder: a longitudinal controlled study. Rev Bras Anestesiol. 2014. http://dx.doi.org/10.1016/j.bjane.2014.06.008
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C.B. Battistella et al. Conclusions: In our population, the incidence of signs and symptoms of temporomandibular disorder of muscular origin was not different between the groups. © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
PALAVRAS-CHAVE Transtornos da articulac ¸ão temporomandibular; Síndrome da dor miofascial; Anestesia geral; Intubac ¸ão; Dor orofacial
Intubac ¸ão orotraqueal e disfunc ¸ão temporomandibular: estudo longitudinal controlado Resumo Justificativa e objetivos: Determinar a incidência de sinais e sintomas de disfunc ¸ão temporomandibular (DTM) em pacientes de cirurgia eletiva submetidos à intubac ¸ão orotraqueal. Métodos: Estudo longitudinal controlado com dois grupos. O grupo de estudo incluiu pacientes que foram submetidos à intubac ¸ão orotraqueal e um grupo controle. Usamos o questionário da Academia Americana de Dor Orofacial (AAOP) para avaliar os sinais e sintomas da DTM no primeiro dia de pós-operatório (T1), e os estados basais dos pacientes antes da cirurgia (T0) também foram registrados. O mesmo questionário foi usado após três meses (T2). A amplitude da abertura bucal foi medida em T1 e T2. Consideramos um valor-p inferior a 0,05 como significativo. Resultados: No total, 71 pacientes foram incluídos, com 38 pacientes no grupo de estudo e 33 no grupo controle. Não houve diferenc ¸a significativa entre os grupos quanto à idade (grupo de estudo: 66,0 [52,5-72,0]; grupo controle: 54,0 [47,0-68,0], p = 0,117) ou gênero feminino (grupo de estudo: 57,9%; grupo controle: 63,6%, p = 0,621). No T1, não foram encontradas diferenc ¸as estatisticamente significativas entre os grupos quanto à incidência de limitac ¸ão de abertura bucal (grupo de estudo: 23,7% vs. grupo controle: 18,2%, p = 0,570) ou amplitude de abertura bucal (grupo de estudo: 45,0 [40,0-47,0] vs. grupo controle: 46,0 [40,0-51,0], p = 0,278). Em T2, os resultados obtidos foram semelhantes. Não houve diferenc ¸a significativa na resposta afirmativa a todas as perguntas individuais do questionário AAOP. Conclusões: Em nossa populac ¸ão, a incidência de sinais e sintomas de DTM de origem muscular não foi diferente entre os grupos. © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.
Introduction Temporomandibular disorder (TMD) comprises a number of clinical conditions involving the masticatory muscles, the temporomandibular joint (TMJ) and associated structures. The common signs and symptoms of TMD are clicking noises in the TMJ, a limited jaw opening capacity, deviations in the movement patterns of the mandible and masticatory muscles and TMJ or facial pain.1---3 TMD is, by far, the most prevalent of all chronic orofacial pain conditions.4 The prevalence of TMD among individuals presenting at least one clinical sign varies from 40% to 75%.2 In Brazil, at least one TMD symptom was reported by 39.2% of the population.5 Sounds in the TMJ and deviations in mouth opening and closing movements occur in approximately 50% of the nonpatient population and are considered normal, with no need for treatment.6 The most common subtype is TMD of muscular origin,7 and it is characterized by localized pain and tenderness in the masticatory muscles.8 During intubation, the TMJ rotation and translation maneuvers used by the anesthesiologist to achieve a maximum opening of the patient’s mouth and the atraumatic
passage of an endotracheal tube may result in damage to the TMJ apparatus due to the excessive forces being applied either manually or with the laryngoscope. Additionally, damage may occur due to the length of time that the structures are in a ‘‘stressed’’ position. Orotracheal intubation has long been considered a risk factor for the development or exacerbation of TMD that includes facial pain.9,10 Some studies have described changes in the structures of the masticatory system after orotracheal intubation. These changes can be of either articular11 or articular and muscular origin.9,12,13 In contrast, a study showed that intubation techniques do not represent a risk for the development of TMD.14 An update of the guidelines for the management of the difficult airway by the American Society of Anesthesiologists specifically recommends the preoperative assessment of the TMJ function.15,16 However, the current evidence in the literature is based on case reports10,17---20 and small studies.9,11---13,20 Thus, the aim of this study was to evaluate the incidence of signs and symptoms of TMD of muscular origin in elective surgery patients who underwent orotracheal intubation compared with patients without intubation.
Please cite this article in press as: Battistella CB, et al. Orotracheal intubation and temporomandibular disorder: a longitudinal controlled study. Rev Bras Anestesiol. 2014. http://dx.doi.org/10.1016/j.bjane.2014.06.008
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Orotracheal intubation and temporomandibular disorder
Methods This was a longitudinal controlled study conducted on elective surgical inpatients from a university hospital. The study was approved by the institutional Research Ethics Committee under the number 00595012.1.0000.5505, and all the subjects signed the written informed consent form. We included consecutive patients older than 18 years of age who were admitted to the intensive care unit (ICU) after elective surgery under general anesthesia. Those patients were divided into 2 groups. The study group consisted of the patients who underwent orotracheal intubation for general anesthesia, and the control group included the patients who underwent an alternate anesthesia procedure without intubation. In the control group, we also included patients in the postoperative care wards. We excluded the patients unable to answer the questionnaire or to sign the consent form, those with a tracheostomy or using a laryngeal mask during surgery, those undergoing head or neck surgeries and those with facial or TMJ trauma or with previous treatment for TMD or orofacial pain. The demographic data, age, gender and duration of the intubation were recorded. After inclusion, the patients answered a modified TMD screening questionnaire from the American Academy of Orofacial Pain (AAOP).2 This questionnaire has 10 objective questions about the most frequent TMD and orofacial pain signs and symptoms. As we could not assess the patients before surgery, they were asked to answer the questions referring both to their baseline status prior to surgery (T0) and their actual postoperative status (T1). Questions 8 and 10 were not evaluated because the patients in the study could not have the referral conditions because of our exclusion criteria. We also measured the maximum mouth opening amplitude of these patients with a disposable paper ruler as previously described.21 We measured the distance between the upper and lower central incisors while the patients opened their mouths. In prostheses users who were without them, we measured the distance from the right central incisor to the antagonist alveolar edge, subtracting 10 mm if they were partially edentulous. In the case of a total edentulous patient, we measured the distance from the upper to lower alveolar edge, subtracting 15 mm as previously reported.22 The mouth opening was measured by a single examiner. The patients received a similar paper ruler and instructions for its use. After 3 months (T2), the questionnaire was reapplied by telephone, and the maximum mouth opening was measured by the patient under the same conditions as at T1 (with or without prostheses). We considered a measurement of less than 40 mm to be a mouth opening limitation.23 We considered the patients who had one or more positive responses to the AAOP screening questionnaire to have TMD signs and symptoms.
Statistical analysis The sample size was calculated based on the frequency of mouth opening limitation (
